Child's plexus palsy

from Wikipedia, the free encyclopedia

In child plexus palsy , also birth-associated ( obstetric ) or birth-traumatic or infantile arm paralysis / brachial plexus injury / plexus paralysis , it is an injury to the arm nerve plexus ( brachial plexus ) during birth. It leads to a disruption of arm movement and sensitivity of varying degrees. Depending on the number of nerve roots involved and the severity of the damage, the extent of the paralysis is extensive and long-lasting. Serious injuries result in permanent limitation of the mobility of the arm, permanent sensory disorders, altered growth of the extremities and restricted usability with secondary psychosocial consequences.

A famous victim was Kaiser Wilhelm II.

Risk factors

Most of the time, plexus palsy is caused by increased stretching of the arm nerve plexus and associated with a more difficult birth if the child's shoulder becomes entangled after the head is born first and increased tension is exerted on the neck region during obstetrics (see shoulder dystocia ). This emergency situation occurs more frequently with an increased birth weight of the newborn ( macrosomia , i.e. a birth weight over 4000 g), the use of mechanical obstetrics ( forceps , vacuum ) or in an emergency situation such as an umbilical cord loop or a sudden lack of oxygen in the fetus. In rare cases, if the child is in breech position and development is normal, one or more nerve roots may be sheared off due to axial traction in the spinal cord (torn nerve roots in breech birth). A cesarean section can also lead to plexus palsy due to the increased pulling force on the neck of the rapidly developing fetus.

Expression

The anatomy of the brachial plexus above the clavicle (supraclavicular) comprises the five nerve roots C5, C6, C7, C8 and Th1 as well as the three nerve trunks (superior, medius and inferior trunk) that arise from them. In simplified terms, roots C5 and C6 supply the shoulder and the elbow flexion; the root C7 the pectoral muscle and the extension of the elbow; and C8 and Th1 the hand.

Correspondingly, in the clinical examination of the newborn, a distinction is made between the upper (concerning the roots C5 and C6), the extended upper (plus C7) and the complete plexus palsy (all roots are affected). Very rarely the damage is centered on the middle part of the brachial plexus (C7-centered paresis). A purely lower paresis with involvement of the roots C8 and Th1 alone, as can occur in adults in the event of accidental injuries, is extremely rare in newborns, or is controversial or nonexistent.

The extent of injury to the respective nerve roots can vary greatly from root to root due to the different tensile force and different anatomically predetermined holding mechanisms (ligament structures). As the tensile force increases, the nerve is stretched first, then tears, tears and finally, as the most severe nerve injury, parts of the roots are torn out of the spinal cord, and finally one or more complete root tears. The latter are injuries close to the spinal cord (damage to the central nervous system), which occur more often in the breech position on the roots C5 and C6 and in the case of severe traction damage in the context of complete plexus palsy on the lower roots C8 and Th1.

treatment

Physiotherapy and occupational therapy

The affected children should be cared for by an experienced physiotherapist during all major phases of paralysis. In the first ten days of life, the injured neck region must be spared and the affected arm placed against the body with the elbow bent (a safety pin is often sufficient to fix the sleeve to the front part of the upper body fabric). The nerves injured by tension and the soft tissue surrounding them must recover from the trauma, accompanying bruises and swellings should subside - immediate protection is sufficient for this.

Thereafter, the onset of nerve regeneration should be accompanied by therapeutic measures and work towards the age-typical movement patterns. In the German-speaking countries, the methods according to Vojta and Bobath have proven themselves with small children , whereby an excessive burden on the mother-child relationship by transferring too much responsibility to the parents must be avoided. Already in the first weeks of life it is important to ensure that the glenohumeral joint can move freely in order to counteract internal rotational misalignment and further incorrect growth of the humeral head. Simple passive stretching exercises with an upper arm placed on the upper body in alternating internal and external rotation by the therapist and at home by the parents have proven themselves here.

After an operative nerve reconstruction, the progressive nerve regeneration must again be taken into account. The movement recovery usually begins after four to six months at the earliest. As soon as active movements become visible again, an active movement path can be included in the exercise program again and promote the improvement of movement patterns.

After secondary interventions, usually tendon or muscle transfers, in addition to general therapy after six weeks of healing time for the tendon suture, the new function must be selectively “trained” and the muscle that has been relocated for the new function must be encouraged to build up strength for at least one year, as the latter has a morphological and physiological adaptation to the new movement goes through and is only available in its best form after this period of time. For larger, cooperative children, occupational therapy approaches (playful practice of movement sequences useful for everyday life: getting dressed, brushing teeth, blow-drying their hair ...) are useful; Any sporting activity that makes good use of the arm should be encouraged (ball games, swimming ...). Even the best therapy method has to come to an end - and this has to be scheduled and openly discussed between the prescribing pediatrician, the therapist and the little patient and his or her parents.

Surgical procedure

Restorative (reconstructive) interventions from the fields of plastic and hand surgery, neurosurgery and orthopedics endeavor to ensure the best possible general motor and sensitive function of the affected upper extremity in the event of severe injuries to the brachial plexus, first through microsurgical nerve reconstruction and later through secondary so-called motor replacement operations to restore, whereby an impairment-free recovery never succeeds.

Early nerve reconstruction

If the nerves are severely injured, torn and / or nerve roots torn out, early nerve interventions in the first few months of life try to restore the continuity of functioning nerve pathways as well as possible. The diagnosis of small children is essentially confirmed by observing the improvement in movement in the first three to nine months of life. Additional electrophysiological examinations or imaging ( MRT , MyeloCT ) are rarely used ; the latter also only allow indications of avulsed nerve roots. In the case of severe, complete plexus palsy, surgical treatment should be decided within the first three months of life; in the case of partial palsy, a period of up to around nine months is permissible.

Here is a brief description of the microsurgical rehabilitation of the injury after showing the nerve plexus on the side of the neck: Neurolysis removes scarring around the nerves and within the outer tissue layers of the nerve pathways, in the hope of improving the electrical conductivity of the nerve pathways. If nerve roots or trunks are torn, new nerve connections ( anastomoses ) can be established after resection of the scarred injury stumps either by direct coaptation of the nerve endings or by interposition of uninjured nerve pieces. Donor nerves are taken from a different part of the child's body in such a way that no significant functional failure results: sensitive nerves on the lower leg or forearm and sensitive nerves on the triangle neck.

If nerve roots are torn out, the connection to the cervical medulla is irretrievably lost. Then the severed nerve pathways have to be revived by rerouting other (preferably motor) nerve donors or by folding them onto remaining nerve root stumps. The latter procedure is known as intraplexic reconstruction (the functionally important pathways are supplied by remaining nerve stumps). The former are called extraplexic procedures because nerve donors are used outside the brachial plexus. These are motor cranial nerves (accessory nerve), intercostal nerves, in rare cases nerves of the healthy arm (contralateral transfer).

In recent years, so-called nerve transfers have become established, with healthy motor nerve fascicles being diverted from uninjured trunk nerves in the region in order to occupy important motor target functions. Examples are the restoration of elbow flexion through motor fascicles from the ulnar and / or median nerve or shoulder abduction through motor components from the radial nerve.

Secondary corrective interventions

Three or four years after the primary operation, tendons or muscles can be repositioned to improve functionality. Important prerequisites are a freely movable joint and a strong dispensable donor muscle. These interventions depend on a comprehensive muscle solution with preservation of the vascular nerve bundle (the intact blood circulation and motor nerve supply are essential for the further function of the displaced muscle). In addition, the muscles must be rearranged in the direction of the pulling direction of the target function and attention must be paid to good tendon end fixation (in a tendon or directly in the bone).

Various redistributions with more or less good functional gain are available for all joints. Every muscle transfer must be accompanied by physiotherapy for at least one year postoperatively. A special feature is the gradual correction of the internal rotation contracture of the shoulder joint.

Shoulder contracture and glenohumeral malformation

If opposing muscle groups in a joint create an unbalanced balance of forces due to paralysis that is different in the individual muscles, the bony joint partners are deformed. In childhood plexus palsy, the various joints of the upper extremity are involved in different ways. On the shoulder, the different recovery of the internal and external rotating muscles leads to a misalignment of the humeral head in internal rotation, with the joint capsule shrinking so that the mobility of the glenohumeral joint is restricted and the humeral head is increasingly displaced backwards. It assumes a dorsal, eccentric position and the small joint tub of the shoulder blade is deformed with a posterior extension and anterior stunting. The joint that deforms progressively and permanently (glenohumeral dysplasia ) becomes more susceptible to wear and tear ( omarthrosis ) due to the biomechanically unfavorable balance of forces . Joint changes can also occur in the elbow and wrist: dislocation of the radial head, elbow joint contracture, reduced growth of the elbow head with lateral deviation of the wrist.

In particular, the internal rotation contracture of the shoulder requires consistent treatment through early stretching exercises and, if necessary, surgical step therapy ( botulinum toxin treatment of the internally rotating subscapularis muscle, plaster immobilization in external rotation after manual repositioning of the joint in external rotation, new control of the suprascapular nerve responsible for active external rotation, operative Shoulder solution, muscle shifting to increase the active external rotation of the shoulder).

General information

In addition to conservative and surgical treatment, many general tips on how to live, how to deal with legal issues and how to gradually adjust to our environment are helpful for parents and affected children. It is absolutely important not to label the child with their changed motor skills as globally disabled or to demotivate them in their efforts in sport through performance-oriented evaluation: In kindergarten and school everyone must take into account that arm paralysis individually restricts the benefit and range of motion of the arm and therefore depends on the Arbitrarily, unchangeable physical characteristics that cannot be influenced are not allowed to be the subject of the grade. In addition, the reduced function leads in the long term to a relative neglect ( neglect ) of the arm, to a changed and sometimes "disturbed" body image and self-esteem, which can be disadvantageous or stressful, especially during puberty.

Even if there are no medically justified restrictions on exercise, the arm is only limited in strength and resilience. This can have a significant impact on the choice of sports, duration of performance and of course the choice of profession.

forecast

The development is individual and is based on the severity of the injury (number and severity of the nerve root injuries, especially the presence of root avulsions), the scope of the microsurgical nerve reconstruction, accompanying growth disorders, the type and number of secondary interventions, but also the physiotherapeutic care, and the influence of others Illnesses, especially overweight children.

Discussion points

There is no absolute agreement on the origin, confirmation of the diagnosis, or conservative and surgical treatment. Medical knowledge is in flux, and different views from parents and surgeons lead to very individual treatment plans and end results. The importance of physiotherapy measures (and their remuneration) is also discussed differently. Decisions regarding a nerve reconstruction have to be made in the first months of life due to the increasing muscle wasting, but with regard to the timing and the exact surgical steps are specific to the practitioner. It is similar with the selection of secondary interventions. How plexus palsy affects the rest of life has only been incompletely studied and is the subject of a regular exchange of ideas between parents, those affected and therapists.

The legal dispute about the responsibility and legal consequences in the event of plexus palsy is very complex. If the cause turns out to be incorrect in treatment, this can result in compensation for pain and suffering and claims for damages. They can be significant because they are designed to compensate for follow-up costs and suffering for the rest of your life. One treatment error is the use of the absolutely contraindicated Kristeller handle in the presence of shoulder dystocia. Due to the peculiarities of medical liability law , however, it cannot be said that every birth-trauma plexus palsy inevitably leads to a case of medical liability.

literature

  • J. Bahm: Obstetric brachial plexus palsy - clinics, pathophysiology and surgical treatment. In: Handchir Mikrochir Plast Chir. 2003 35, pp. 83-97.
  • J. Bahm, L. Meinecke, V. Brandenbusch, G. Rau, C. Disselhorst-Klug: High spatial resolution electromyography and video-assisted movement analysis in children with obstetric brachial plexus palsy. In: Hand Clinics. 2003 19, pp. 393-399.
  • J. Bahm: Secondary procedures in obstetric brachial plexus lesions. In: Handchir Mikrochir Plast Chir , 2004 36, pp. 37-46.
  • J. Bahm, M. Becker, C. Disselhorst-Klug, C. Williams, L. Meinecke, H. Müller, B. Sellhaus, JM Schröder, G. Rau: In: Surgical Strategy in Obstetric Brachial Plexus Palsy - the Aachen Experience . Seminars in Plastic Surgery 2004 18, pp. 285-299.
  • J. Bahm, H. Noaman, M. Becker: The dorsal approach to the suprascapular nerve in neuromuscular reanimation for obstetric brachial plexus lesions. In: Plast Reconstr Surg . 2005 115, pp. 240-244.
  • J. Bahm, C. Ocampo-Pavez, H. Noaman: Microsurgical technique in obstetric brachial plexus repair: a personal experience in 200 cases over 10 years. In: J Brachial Plexus Peripheral Nerve Injury. 2007 2, pp. 1-7.
  • J. Bahm, B. Wein, G. Alhares, C. Dogan, K. Radermacher, F. Schuind: Assessment and treatment of glenohumeral joint deformities in children suffering from obstetric brachial plexus palsy. In: J Ped Orthop. 2007 16B, pp. 243-251.
  • J. Bahm: Changes in rotatory movements of the shoulder after obstetric brachial plexus lesion: clinical condition, surgery, and analysis of objective prognostic factors. Habilitation thesis . Free University of Brussels, 2011.

See also

Web links

Individual evidence

  1. ↑ Explanations on the medical law processing of birth-trauma plexus palsy , accessed on December 13, 2015